Geriatric MedicineTier 1Disease (DEADMAN)

Ulcers - traumatic

Description

Skin/soft tissue breach from mechanical injury (skin tear, laceration, friction) rather than vascular/pressure/neuropathic aetiology
Skin tears - most common traumatic wound in older adults
- Separation of epidermis from dermis (partial) or full-thickness, from shear/friction/blunt trauma
Distinguish from other ulcer types by mechanism + location (not necessarily over pressure points or in venous/arterial distribution)

Epidemiology

Skin tears: ~1.5 million/year in Australian aged care and hospital settings (frequently cited estimate)
F>M reported in some series (reflects care burden/exposure), age >75 predominant
Common sites - forearms, dorsal hands, shins (thin, poorly supported skin)

Aetiopathogenesis

Skin fragility - dermal thinning, dec collagen/elastin, flattened dermo-epidermal junction (age-related)
Corticosteroid use -> further thinning ("steroid skin")
Anticoagulant/antiplatelet therapy -> inc bleeding, haematoma-associated tears
Mechanism - adhesive tape removal, transfers, equipment trauma, falls, pet/carer contact
Poor nutrition, dehydration -> reduced tissue resilience

Diagnosis

Clinical - classify by validated system (e.g. ISTAP: Category 1 no tissue loss / 2 partial flap loss / 3 total flap loss)
Assess flap viability, wound bed, surrounding skin
Exclude non-accidental injury - pattern inconsistent with history, multiple ages of injury, delayed presentation (elder abuse screen)
Assess for underlying contributing pathology - falls risk, anticoagulation, cognition (self-care capacity)

Management

Immediate

Control bleeding, cleanse, realign viable flap if present (moist flap replacement improves healing)
Non-adherent dressing, avoid tape directly on fragile skin (use tubular retention bandage/wraps)
Analgesia

By risk factor

Review anticoagulation - balance thrombotic vs bleeding risk, do not cease reflexively
Skin integrity program - moisturisers, avoid soap, protective clothing/shin guards, environmental modification (padding sharp furniture edges)
Falls risk assessment and prevention plan
Nutrition review

Monitoring

Review at 24-48h for flap viability, then per dressing regimen
Photograph + measure for wound tracking
Escalate if signs of infection or non-healing beyond expected timeframe

Associations

Falls, frailty, sarcopenia
Long-term corticosteroid use
Anticoagulant/antiplatelet therapy
Cognitive impairment - impaired self-protection and reporting
Elder abuse/neglect - must be considered in the differential

Natural history & complications

Most heal within 1-3 weeks with appropriate care if flap preserved
Poor flap viability, malnutrition, anticoagulation, or infection prolong healing / risk chronic wound
Recurrent skin tears predict future falls and frailty progression

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